Abstract
Eosinophilic oesophagitis (EE) is a clinico-pathological entity recognized with increased frequency in children and adults. It is an atopic disease involving ingested and inhaled allergens. A pathological eosinophilic infiltrate is diagnosed by finding ≥15 eosinophils per high-powered field on oesophageal mucosal biopsies. This infiltrate may result in a narrowed oesophageal lumen. It does not involve the stomach or duodenum. Children commonly present with abdominal pain, vomiting and dysphagia. Presentation in adults is with dysphagia, heartburn, chest pain or impaction of a food bolus in the oesophagus. There is often a history of allergy (asthma, hay fever, eczema). A male predominance (70% in adults) is unexplained. Distinctive endoscopic features are linear furrows, mucosal rings and white papules, and the narrowed lumen may be appreciated. Although EE and gastro-oesophageal reflux disease are separate entities, there is a significant overlap of the conditions. Treatment options include nonpharmacological approaches including an elimination or elemental diet, and/ or medications, chiefly with corticosteroids. The topical administration of fluticasone propionate has been demonstrated to improve symptoms and mobilize the pathological infiltrate of eosinophils. There has been a variable effect with the leukotriene receptor antagonist montelukast and promising early results with mepolizumab, a monoclonal antibody against interleukin-5. The long-term efficacy of topical corticosteroids has not been well studied and most patients experience recurrent symptoms when treatment is completed. Currently, repeated short courses of topical corticosteroids are utilized. Acid suppression by a proton pump inhibitor may be considered in view of the overlap between EE and gastro-oesophageal reflux disease.
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References
Franciosi JP, Liacouris CA. Eosinophilic esophagitis. Immunol Allergy Clin N Am 2009; 29: 19–27
Kelly KJ, Lazenby AJ, Rowe PC, et al. Eosinophilic esophagitis attributed to gastroesophageal reflux: improvement with an amino acid-based formula. Gastroenterology 1995; 109: 1503–12
Teitelbaum JE, Fox VL, Twarog FJ, et al. Eosinophilic esophagitis in children: immunopathological analysis and response to fluticasone propionate. Gastroenterology 2002; 122: 1216–25
Sgouros SN, Bergele C, Mantides A. Eosinophilic esophagitis in adults: a systematic review. Eur J Gastroenterol Hepatol 2006; 18: 211–7
Remedios M, Campbell C, Jones DM, et al. Eosinophilic esophagitis in adults: clinical, endoscopic, histologic findings, and response to treatment with fluticasone propionate. Gastrointest Endosc 2006; 63: 3–12
Noel RJ, Putnam PE, Rothenberg ME. Eosinophilic esophagitis. N Engl J Med 2004; 351: 940–1
Patel SM, Falchuk KR. Three brothers with dysphagia caused by eosinophilic esophagitis. Gastrointest Endosc 2005; 61(1): 165–7
Rothenberg ME, Spergel JM, Sherrill JD, et al. Common variants at 5q22 associate with pediatric eosinophilic esophagitis. Nat Genet 2010 Apr; 42(4): 289–91
Gonsalves N, Policarpio-Nicolas M, Zhang Q, et al. Histopathologic variability and endoscopic correlates in adults with eosinophilic esophagitis. Gastrointest Endosc 2006; 64(3): 313–9
Simon D, Marti H, Heer P, et al. Eosinophilic esophagitis is frequently associated with IgE-mediated allergic airway diseases. J Allergy Clin Immunol 2005; 115: 1090–2
Liacouras CA, Spergel JM, Ruchelli E, et al. Eosinophilic esophagitis: a 10-year experience in 381 children. Clin Gastroenterol Hepatol 2005; 3: 1198–206
Prasad GA, Alexander JA, Schleck CD. Epidemiology of eosinophilic esophagitis over three decades in Olmsted County, Minnesota. Clin Gastro Hepatol 2009; 7: 1055–61
Fogg MI, Ruchelli E, Spergel JM. Pollen and eosinophilic esophagitis. J Allergy Clin Immunol 2003; 112: 796–7
Onbasi K, Sin AZ, Doganavsargil B, et al. Eosinophil infiltration of the oesophageal mucosa in patients with pollen allergy during the season. Clin Exp Allergy 2005; 35: 1423–31
Wang FY, Gupta SK, Fitzgerald JF. Is there a seasonal variation in the incidence or intensity of allergic eosinophilic esophagitis in newly diagnosed children? J Clin Gastroenterol 2007; 41: 451–3
Chehade M, Sampson HA. Epidemiology and etiology of eosinophilic esophagitis. Gastrointest Endoscopy Clin N Am 2008; 18: 33–44
Cherian S, Smith NM, Forbes DA. Rapidly increasing prevalence of eosinophilic oesophagitis in Western Australia. Arch Dis Child 2006; 91: 1000–4
Straumann A, Simon HU. Eosinophilic esophagitis: escalating epidemiology? J Allergy Clin Immunol 2005; 115: 418–9
Portmann S, Heer R, Bussmann C. Epidemiology of eosinophilic esophagitis: data from a community-based longitudinal study work carried out by the Swiss EE study group, Switzerland [abstract]. Gastroenterology 2007; 132: A609
Rothenberg ME. Biology and treatment of eosinophilic esophagitis. Gastroenterology 2009; 137: 1238–49
Fox VL, Nurko S, Teitelbaum JE, et al. High-resolution EUS in children with eosinophilic “allergic” esophagitis. Gastrointest Endosc 2003; 57: 30–6
Stevoff C, Rao S, Parsons W, et al. EUS and histopathologic correlates in eosinophilic esophagitis. Gastrointest Endosc 2001; 54: 373–7
Mishra A, Wang M, Pemmaraju VR, et al. Esophageal remodeling develops as a consequence of tissue specific IL-5-induced eosinophilia. Gastroenterology 2008; 134: 204–14
Liacouris CA. Pharmacologic treatment of eosinophilic esophagitis. Gastrointest Endoscopy Clin N Am 2008; 18: 169–78
Furuta GT, Liacouras CA, Collins MH, et al. Eosinophilic esophagitis in children and adults: a systematic review and consensus recommendations for diagnosis and treatment. Gastroenterology 2007; 133: 1342–63
Yan BM, Shaffer EA. Primary eosinophilic disorders of the gastrointestinal tract. Gut 2009; 58: 721–32
Orenstein SR, Shalaby TM, Di Lorenzo C, et al. The spectrum of pediatric eosinophilic esophagitis beyond infancy: a clinical series of 30 children. Am J Gastroenterol 2000; 95: 1422–30
Walsh SV, Antonioli DA, Goldman H, et al. Allergic esophagitis in children: a clinicopathological entity. Am J Surg Pathol 1999; 23: 390–6
Desai TK, Stecevic V, Chang CH, et al. Association of eosinophilic inflammation with esophageal food impaction in adults. Gastrointest Endosc 2005; 61: 795–801
Kerlin P, Jones D, Remedios M, et al. Prevalence of eosinophilic esophagitis in adults with food bolus obstruction of the esophagus. J Clin Gastroenterol 2007 Apr; 41(4): 356–61
Croese J, Fairley SK, Masson JW, et al. Clinical and endoscopic features of eosinophilic esophagitis in adults. Gastrointest Endosc 2003; 58(4): 516–22
Straumann A, Spichtin HP, Bucher KA, et al. Eosinophilic esophagitis: red on microscopy, white on endoscopy. Digestion 2004; 70(2): 109–16
Lim JR, Gupta SK, Croffie JM, et al. White specks in the esophageal mucosa: an endoscopic manifestation of non-reflux eosinophilic esophagitis in children. Gastrointest Endosc 2004; 59(7): 835–8
Vasilopoulos S, Murphy P, Auerbach A, et al. The small-caliber esophagus: an unappreciated cause of dysphagia for solids in patients with eosinophilic esophagitis. Gastrointest Endosc 2002; 55(1): 99–106
Dahshan A, Rabah R. Correlation of endoscopy and histology in the Gastroesophageal mucosa in children: are routine biopsies justified? J Clin Gastroenterol 2000; 31: 213–6
Prasad GA, Talley NJ, Romero Y, et al. Prevalence and predictive factors of eosinophilic esophagitis in patients presenting with dysphagia: a prospective study. Am J Gastroenterol 2007; 102: 2627–32
Straumann A, Bussmann C, Zuber M, et al. Eosinophilic esophagitis: analysis of food impaction and perforation in 251 adolescent and adult patients. Clin Gastroenterol Hepatol 2008; 6: 598–600
Parfitt JR, Gregor JC, Suskin NG, et al. Eosinophilic esophagitis in adults: distinguishing features from gastroesophageal reflux disease: a study of 41 patients. Mod Pathol 2006; 19: 90–6
Collins MH. Histopathologic features of eosinophilic esophagitis. Gastrointest Endoscopy Clin N Am 2008; 18: 59–71
Arora AS, Yamazaki K. Eosinophilic esophagitis: asthma of the esophagus? Clin Gastroenterol Hepatol 2004; 2: 523–30
Konikoff MR, Blanchard C, Kirby C, et al. Potential of blood eosinophils, eosinophil-derived neurotoxin, and eotaxin-3 as biomarkers of eosinophilic esophagitis. Clin Gastroenterol Hepatol 2006; 4(11): 1328–36
Spergel JM, Andrews T, Brown-Whitehorn TF, et al. Treatment of eosinophilic esophagitis with specific food elimination diet directed by a combination of skin prick and patch tests. Ann Allergy Asthma Immunol 2005; 95(4): 336–43
Assa’ad AH, Putnam PE, Collins MH, et al. Pediatric patients with eosinophilic esophagitis: an 8-year follow-up. J Allergy Clin Immunol 2007; 119: 731–8
Spergel JM, Beausoleil JL, Mascarenhas M, et al. The use of skin prick tests and patch tests to identify causative foods in eosinophilic esophagitis. J Allergy Clin Immunol 2002; 109: 363–8
Spergel JM, Brown-Whitehorn T, Beausoleil JL, et al. Predictive values for skin prick test and atopy patch test for eosinophilic esophagitis. J Allergy Clin Immunol 2007; 119: 509–11
Assa’ad A. Detection of causative foods by skin prick and atopy patch tests in patients with eosinophilic esophagitis: things are not what they seem. Ann Allergy Asthma Immunol 2005; 95: 309–11
Kagalwalla AF, Sentongo TA, Ritz S, et al. Effect of six-food elimination diet on clinical and histologic outcomes in eosinophilic esophagitis. Clin Gastroenterol Hepatol 2006; 4(9): 1097–102
Gonsalves N, Yang G, Doerfler B, et al. A prospective clinical trial of six food elimination diet and reintroduction of causative agents in adults with eosinophilic esophagitis [abstract]. Gastroenterology 2008; 134: A104
Markowitz JE, Spergel JM, Ruchelli E, et al. Elemental diet is an effective treatment for eosinophilic esophagitis in children and adolescents. Am J Gastroenterol 2003; 98: 777–82
Schoepfer AM, Gschossmann J, Scheurer U, et al. Esophageal strictures in adult eosinophilic esophagitis: dilation is an effective and safe alternative after failure of topical corticosteroids. Endoscopy 2008; 40: 161–4
Cohen MS, Kaufman AB, Palazzo JP, et al. An audit of endoscopic complications in adult eosinophilic esophagitis. Clin Gastroenterol Hepatol 2007; 5: 1149–53
Eisenbach C, Merle U, Schirmacher P, et al. Perforation of the esophagus after dilation treatment for dysphagia in a patient with eosinophilic esophagitis. Endoscopy 2006; 38 Suppl. 2: E43–4
Gonsalves N, Karmali K, Hirano I. Safety and response of esophageal dilation in adults with eosinophilic esophagitis [abstract]. Gastroenterology 2007; 132 Suppl. 2: T2034
Dellon ES, Gibbs WB, Rubinas TC, et al. Esophageal dilation in eosinophilic esophagitis: safety and predictors of clinical response and complications. Gastrointest Endosc 2010 Apr; 71(4): 706–12
Dohil R, Newbury R, Fox L, et al. Oral viscous budesonide is effective in children with eosinophilic esophagitis in a randomized, placebo-controlled trial. Gastroenterology 2010; 139: 418–29
Molina-Infante J, Ferrando-Lamana L, Ripoll C, et al. Esophageal eosinophilic infiltration responds to proton pump inhibition in most adults. Clin Gastroenterol Hepatol 2011 Feb; 9(2): 110–7
Liacouras CA, Wenner W, Voytek T, et al. Primary eosinophilic esophagitis in children: successful treatment with oral corticosteroids. J Pediatr Gastroenterol Nutr 1998; 26(4): 380–5
Schaefer ET, Fitzgerald JF, Molleston JP, et al. Comparison of oral prednisone and topical fluticasone in the treatment of eosinophilic esophagitis: a randomized trial in children. Clin Gastroenterol Hepatol 2008; 6(2): 165–73
Faubion Jr W, Perrault J, Burgart LJ, et al. Treatment of eosinophilic esophagitis with inhaled corticosteroids. J Pediatr Gastroenterol Nutr 1998; 27(1): 90–3
Arora AS, Perrault J, Smyrk TC. Topical corticosteroid treatment of dysphagia due to eosinophilic esophagitis in adults. Mayo Clin Proc 2003; 78: 830–5
Konikoff MR, Noel RJ, Blanchard C, et al. A randomized, double-blind, placebo-controlled trial of fluticasone proprionate for pediatric eosinophilic esophagitis. Gastroenterology 2006; 131(5): 1381–91
Noel RJ, Putnam PE, Collins MH, et al. Clinical and immunopathologic effects of swallowed fluticasone for eosinophilic esophagitis. Clin Gastroenterol Hepatol 2004; 2(7): 568–75
Aceves SS, Bastian JF, Newbury RO, et al. Oral viscous budesonide: a potential new therapy for eosinophilic esophagitis in children. Am J Gastroenterol 2007; 102(10): 2271–9
Aceves SS, Dohil R, Newbury RO, et al. Topical viscous budesonide suspension for treatment of eosinophilic esophagitis [letter]. J Allergy Clin Immunol 2005; 116(3): 5–6
Straumann ADL, Conus S, Degen L, et al. Budesonide is effective in adolescent and adult patients with active eosinophilic esophagitis. Gastroenterology 2010; 139: 1526–37
Lindberg GM, Van Eldik R, Saboorian MH. A case of herpes esophagitis after fluticasone propionate for eosinophilic esophagitis. Nat Clin Pract Gastroenterol Hepatol 2008 Sep; 5(9): 527–30
Gawrieh S, Shaker R. Treatment options for eosinophilic esophagitis: montelukast. Curr Gastroenterol Rep 2004; 6(3): 190
Sinharay R. Eosinophilic oesophagitis: treatment using montelukast. Gut 2003; 52(8): 1228–9
Attwood SE, Lewis CJ, Bronder CS, et al. Eosinophilic oesophagitis: a novel treatment using montelukast. Gut 2003; 52(2): 181–5
Mepolizumab: 240563, anti-IL-5 monoclonal antibody — GlaxoSmithKline, anti-interleukin-5 monoclonal antibody — GlaxoSmithKline, SB 240563. Drugs R D 2008; 9 (2): 125–30
Garrett JK, Jameson SC, Thomson B, et al. Anti-interleukin-5 (mepolizumab) therapy for hypereosinophilic syndromes. J Allergy Clin Immunol 2004; 113: 115–9
Stein ML, Collins MH, Villanueva JM, et al. Anti-IL-5 (mepolizumab) therapy for eosinophilic esophagitis. J Allergy Clin Immunol 2006 Dec; 118(6): 1312–9
Straumann A, Conus S, Grzonka P, et al. Anti-interleukin-5 antibody treatment (mepolizumab) in active eosinophilic oesophagitis: a randomized, placebo-controlled, double-blind trial. Gut 2010 Jan; 59(1): 21–30
Straumann A, Bussmann C, Conus S, et al. Anti-TNF-alpha (infliximab) therapy for severe adult eosinophilic esophagitis. J Allergy Clin Immunol 2008; 122: 425–7
Netzer P, Gschossmann JM, Straumann A, et al. Corticosteroid-dependent eosinophilic oesophagitis: azathioprine and 6-mercaptopurine can induce and maintain long-term remission. Eur J Gastroenterol Hepatol 2007; 19: 865–9
Acknowledgements
The authors thank Associate Professor Andrew Clouston for the histology images. The authors thank Professor Marc E. Rothenberg, Director, Division of Allergy and Immunology, Director, Cincinnati Center for Eosinophilic Disorders, Professor of Pediatrics, Cincinnati Children’s Hospital Medical Center University of Cincinnati College of Medicine, Cincinnati, OH, USA, for permission to use figure 1.
No sources of funding were used to assist in the preparation of this review. The authors have no conflicts of interest that are directly relevant to the content of the review.
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Remedios, M., Jones, D. & Kerlin, P. Eosinophilic Oesophagitis. Drugs 71, 527–540 (2011). https://doi.org/10.2165/11585450-000000000-00000
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DOI: https://doi.org/10.2165/11585450-000000000-00000